Provider Demographics
NPI:1205247772
Name:WIGAND, JASON PAUL (AUD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:PAUL
Last Name:WIGAND
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 48TH AVE N STE 101
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5434
Mailing Address - Country:US
Mailing Address - Phone:843-491-9008
Mailing Address - Fax:843-491-9009
Practice Address - Street 1:950 48TH AVE N STE 101
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5434
Practice Address - Country:US
Practice Address - Phone:843-491-9008
Practice Address - Fax:843-491-9009
Is Sole Proprietor?:No
Enumeration Date:2014-05-18
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4013237600000X, 231H00000X
OHA01894231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1527Medicaid